On April 1, 2013, the Legal Aid Foundation of Colorado kicked off its annual Associates Campaign. For many young lawyers, the Associates Campaign will be their first exposure to the work of Colorado Legal Services (CLS), the Legal Aid Foundation’s sole beneficiary. Although the Campaign traditionally has been fueled by healthy competition among law firms, it fundamentally exists for one reason: to help keep the lights on at the only legal organization able to serve hundreds of thousands of impoverished Coloradans, many of whom are children.

This article discusses just one important CLS program that needs additional funding to stay afloat—the Medical–Legal Partnership for Children. It is not alone in requiring public support to survive. Colorado lawyers can help support this program and CLS programs generally by participating in the Associate’s Campaign at their firm or by visiting www.legalaidfoundation.org and selecting "Donate Now."

"These Things Happen All the Time"

"We shouldn’t have kids dying because they can’t get their asthma medication," says Ellen Alires-Trujillo, a CLS staff attorney. Unfortunately, that is exactly what happened in 2009 when, at Children’s Hospital Colorado (Children’s Hospital), the mother of 9-year-old Zumante Lucero made the impossible decision to disconnect him from his respirator. He died four minutes later.

As The Denver Post reported at the time, Zumante had suffered from asthma since he was 3 months old.1It became worse as he grew older. His physician prescribed Advair, an inhaled medicine, to control his asthma. His mother applied for Medicaid benefits to pay for it. For a while, things seemed okay.

A few months before Zumante’s death, however, the pharmacy refused to fill his prescription, telling his mother that he was no longer eligible for benefits. For the next four months, Zumante’s mother called Denver Human Services every three days to try to figure out why he had been rejected for medical benefits. The response she usually received was a computer-generated report showing that her son did in fact qualify for Medicaid.

It made no difference; Colorado’s problem-plagued benefits-management computer system informed the pharmacy otherwise. Zumante’s mother continued to try to resolve the problem, all the while treating her son with other medications she still had. When his condition worsened, emergency room doctors at Children’s Hospital gave her free samples of Advair. By then, though, it was too late.

Zumante’s story might be among the most extreme and most tragic examples of the challenges that disadvantaged Colorado children face in obtaining basic medical care, but it is certainly not the only example. Alires-Trujillo says that although Zumante’s death pained her, it didn’t surprise her. "Childrens’ Medicaid benefits [have been] routinely terminated because of computer issues or because paperwork was left sitting on someone’s desk," she explains. CLS Executive Director Jon Asher put it more succinctly: "These things happen all the time."

The Medical–Legal Partnership

Through its Medical–Legal Partnership for Children program, CLS strives to stop such tragedies from occurring. The program pairs physicians and social workers with CLS attorneys to identify cases like Zumante’s—and to intervene before they advance to life-threatening illness.

When a child comes to the emergency room at Children’s Hospital, the immediate focus is on treating the emergency—be it asthma or a broken bone. After doctors stabilize the child, he or she is discharged. Throughout thousands of cases, patterns emerge. The same children keep coming back for treatment of the same conditions. They do not get better. "Some recycle through," says Alires-Trujillo. Equally as problematic is that often the parents of those children who are eligible for public health benefits cannot actually secure them. They feel that medical care for their children is out of reach. Their children never even make it to the hospital.

The Partnership—A Practical
Response to a Social Reality

In 1993, a Boston pediatrician, frustrated with routinely seeing these problems in his practice, founded the first Medical–Legal Partnership in the country. The Partnership was his practical answer to the stark reality that underlying many medical problems are what researchers call the "social determinants of health." For example, many children with asthma emergencies or respiratory infections live in apartments overrun by mold or vermin. Recurring bodily injuries or mental health problems result from domestic violence. A family forced to choose between paying for utilities and paying for preventive medicine makes the difficult decision to keep the heat turned on. These are problems that often can be solved but implicate specialized legal issues that medical residents, and even social workers, lack the knowledge and resources to address.

The Colorado Partnership was established in 2010. The Partnership begins with a referral from either the child’s health clinic or the pulmonary clinic at Children’s Hospital. When parents bring a child to Children’s Hospital, they are asked to complete a simple four-question form:

Do they have housing concerns such as overcrowding, rodents, mold, or lead paint?

Are they past due on rent, mortgage, or utilities?

Do they have trouble obtaining or keeping public benefits?

Do they have concerns about threats to their family’s safety?

More than half of the children assisted by the Partnership have been to the emergency room more than once; a quarter have had five or more emergency room visits. By solving underlying problems, the thinking goes, the cycle of hospitalization and the need for acute treatment can be broken.

Social workers at the hospital screen the forms and try to handle what they can on their own. Those who require legal intervention are marked as "positives." The social workers then send those intake forms to CLS and its Medical–Legal Partnership legal team.

Hundreds of Children in Need—
One-Tenth of a Lawyer to Help Them

The term "legal team" is somewhat of a misnomer; in reality, it comprises Alires-Trujillo and a one-day-a-week volunteer attorney. "I always knew I was going to work in the helping profession," says Alires-Trujillo.

Before becoming an attorney, Alires-Trujillo worked as a case management supervisor at the Adams County Mental Health Center. While at the Mental Health Center, she began helping her clients pursue their own Social Security disability claims and guiding them in handling their own small legal matters. The successes she saw her clients have with her help were life changing. "I found out I could do it," she says. "It was empowering."

After working for several years at Adams County Mental Health Center, she made the decision to attend law school. Alires-Trujillo then enrolled at the University of Denver Sturm College of Law in 1985, and supported herself and her daughter working as a paralegal at CLS.

After passing the bar exam, Alires-Trujillo joined CLS as a full-time staff attorney. She began in the Senior Unit, assisting elders with basic legal problems, and later moved to the Housing Unit, where she dealt with subsidized housing evictions and some foreclosures. After taking a leave of absence to work at the Social Security Administration, she returned to CLS and joined the Health and Elder Unit. "I found while at the Social Security Administration that I missed direct client contact," she explains.

Most of Alires-Trujillo’s work is for the elderly and the disabled and involves Medicaid, Medicare, and Social Security benefits. Even seemingly simple matters like keeping clients in their homes are a challenge. "We provide representation to elders and the disabled in denial of benefit matters, which, if successful, allows them to continue to live in the community with support services," she explains.

About three years ago, Alires-Trujillo began working with the Medical–Legal Partnership. Dr. David Fox, a pediatric physician at Children’s Hospital, champions the program on the medical side. Children’s Hospital has devoted a room to the project where Alires-Trujillo meets with clients. Due to an overwhelming caseload at CLS, however, she can work there only one afternoon a week—which amounts to a mere one-tenth of one attorney’s time.

One Problem, Many Causes

After interviewing the parent of a patient, Alires-Trujillo searches for a solution. In many cases, the problem lies in the home. In asthma cases, mold problems are common. Sometimes, the solution is simple. A letter from a medical provider outlining the danger posed to the child’s health or the mere utterance of the phrase "warranty of habitability" might be enough to get a family out of their lease or improve their housing conditions.

In other cases, resolving the problem is more difficult. In one instance, mold problems were so severe that both a child and his parent were suffering from asthma. A series of letters and phone calls to the apartment complex’s manager were ignored. "He just wasn’t interested in helping," Alires-Trujillo recalls. Only by escalating the issue could she help the family terminate the lease and secure healthier housing.

Sometimes, helping these children means drawing on a wide range of CLS resources. In a case eerily reminiscent of Zumante’s, the Partnership referred an asthmatic child whose medical appointments had been canceled due to the termination of the child’s Medicaid benefits. The termination of benefits also threatened the child’s impending surgery. Meanwhile, the child’s entire family was faced with eviction when their disabled stepfather lost his Social Security benefits. CLS resolved the Medicaid issue, and the child resumed treatment for asthma and had the surgery he needed. CLS also worked with the Social Security Administration to obtain retroactive disability payments for the stepfather, which helped prevent the family’s eviction.

As with most of the services CLS provides, the Partnership strives to help those for whom traditional legal services are out of reach—the 9-month-old child of a homeless teenage mother who cannot apply for public benefits because she is a minor without any identification; the 4-year-old child with kidney disease whose mother cannot get the Department of Human Services to return her phone calls about why her Medicaid status is inactive; the asthmatic child who has to share medication with his brother because benefits have been canceled; the child with diabetes and cystic fibrosis whose parents have a history of criminal and drug-related problems and whose grandparents are willing to care for the child but lack legal authority to do so.

The impact of the program extends beyond solving a child’s immediate medical problems. A successful resolution can help parents cope with other issues. "It’s empowering for them to see that the system can work for them," says Alires-Trujillo. It extends beyond the individual client. She explains: "If someone is able to move into a better environment, the child is less apt to recycle through the hospital system. It’s better for the child, the families, and the community." By getting children the medical benefits to which they are entitled, it also frees up Children’s Hospital’s resources, allowing the hospital to serve more people in need.

Always a Question of Funding

Undertaking a program like the Partnership was not something that CLS could afford to take lightly. The organization is charged with protecting "the basic necessities of a decent life," such as food, shelter, utilities, and medical care, for the entire state. With few exceptions, only those who earn 125% of the federal poverty guideline or less qualify for CLS’s free legal services; for a family of four, this means a household income of less than $29,000. Approximately 880,000 Coloradans meet this financial eligibility criteria. In 2011, the forty-seven lawyers of CLS served 11,534 low-income clients. CLS has less than half the staff it did thirty years ago and more than three times as many clients.

Over the past several years, CLS has lost more than $2.5 million in funding and has replaced only a portion of that. Resources were tight even back in July 2007, when Jon Asher received an e-mail from Alison Montgomery, then a medical student at the University of Colorado. While an undergraduate at Tufts University near Boston, Montgomery had worked at a Medical–Legal Partnership site in Boston. After moving to Colorado, she saw a need for a similar program here.

It only takes Asher a moment or two to find in one of the piles of paper that dominate his office a copy of the e-mail from Montgomery that was forwarded to him in the summer of 2007. On the top, he had scrawled two words: "Reply," and then, underlined for emphasis, "Funding?"

At CLS, determining how to fund vital programs has always been the question for which there is no easy answer. Still, Asher did not hesitate. "We had no money to do it. We just did it," he says. "Apparently that’s not what you’re supposed to do."

He did it anyway. It took several years to get the program off the ground, and by 2010, it was in full swing.

An Uncertain Future

The future of the Medical–Legal Partnership, like most programs at CLS, is uncertain. It doesn’t take much prodding to get Alires-Trujillo to imagine what the program could accomplish with more resources. Many of the same children who cope with serious medical problems also have immigration issues that affect their ability to obtain care. Children with special needs require customized educational plans. The program could logically extend to the needs of the elderly, many of whom also live with medical problems exacerbated by issues that need the attention of a lawyer rather than a doctor.

For now, though, times are increasingly troublesome and the program will continue as funding allows. "We still don’t know what our financial situation will be," Alires-Trujillo explains. "We can’t expand the program, and we can’t provide additional resources for the program right now."

Six years after discussions began, and three years after the project actually was implemented, Asher still does not regret that CLS took on the Medical–Legal Partnership. "But," he adds, "I’m sorry we haven’t gotten the money [to pay for it] yet."

Conclusion

For more than eighty-five years, Colorado Legal Services has been operating under the premise that every Coloradan deserves access to high-quality civil legal services. There are ways to help: establish a 2013 Associate’s Campaign to accept donations or, alternatively, make a donation directly to the Legal Aid Foundation so that CLS can continue to provide vital assistance to the men, women, and children of Colorado who have nowhere else to turn.

Also, it’s not too early to begin planning for 2014. If your firm is interested in participating in next year’s Associate’s Campaign for Justice, contact Diana Poole, Executive Director of the Legal Aid Foundation, at (303) 863-9544 or diana@legalaidfoundation.org.